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Rev 04/01/18 – HCSC Privacy Office (04/23/19 – BORC) Page 1 of 6 SAF-NM
Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association
Instructions for Completing Standard Authorization
Form to Release Protected Health Information (PHI)
To Complete Form go to Page 4
Use this form to authorize Blue Cross and Blue Shield of New Mexico (BCBSNM) to disclose your protected health
information (PHI) to a specific person or entity. You may follow the instructions below or call the number listed on your
Member ID card if you need help completing the form. You must complete the entire form.
Please note:
• One authorization form can be used for multiple services or providers or you can complete the form claim by
claim, procedure by procedure, or for services provided during certain time periods.
• The use of the authorization form is voluntary.
_______________________________________________________________________________________________
Section I. Name and information of person whose PHI is being disclosed
Jane Doe
05-10-1962
Name
Date of Birth
123456
XOP123456789
### - ## - ####
Group Number
Identification/Subscriber Number
Social Security Number
123 Main Street
Address
NM
12345
State
Zip Code
The information in Section I applies to the person whose PHI is being disclosed. The person could be the policy holder,
his or her spouse, a dependent or any other person covered under the policy or a person who has their own coverage.
In this example, Jane Doe is the person making the request.
_______________________________________________________________________________________________
Section II. Authorization and Purpose
I authorize BCBSNM to release my PHI to the person or organization listed below. I understand if the person or
organization listed below is not a health plan or health care provider, the PHI may not be protected by federal privacy laws.
Suzy Smith
Daughter
Persons/Organizations authorized to receive your information
Relationship
Assisting in medical care
Purpose
123 Main Street
Anytown
NM
12345
Address
City
State
Zip Code
The information in Section II identifies the person or organization that will be receiving the PHI about the person named
in Section I. A person that needs access to the PHI could be a family member, a close friend, a broker, or an attorney.
If the person wants PHI to go to an organization, please include the area and/or job title of the person at the organization,
for example, Benefits Representatives, Human Resources Department, Associate XYZ Insurance Agency, etc. In this
example, Jane Doe is authorizing the release of PHI to her daughter Suzy Smith.
Rev 04/01/18 – HCSC Privacy Office (04/23/19 – BORC) Page 2 of 6 SAF-NM
Section III. Description of Sensitive Protected Health Information (SPHI) and PHI to be Released
Complete Parts A and B of this section
A. Release of SPHI that may be protected under State Law. If you check “yes,” you are authorizing BCBSNM to
release the SPHI listed below and if applicable to your data release request, it will be included in the information you
select in III.B. If you check “no” or make no selection at all, SPHI will not be released. This authorization may not be used
for the release of Psychotherapy Notes.
• Human Immunodeficiency Virus (HIV) or HIV/Acquired Immune Deficiency Syndrome,
• Sexually transmitted or “communicable” diseases (includes hepatitis, as well as venereal
diseases),
• Drug, alcohol or substance abuse,
• Mental health or developmental disabilities (including mental retardation or similar disabilities,
for example, those attributable to cerebral palsy, autism or neurological dysfunctions), and
• Genetic testing.
The information in Section III-A applies when a person wants specific SPHI as listed above to be released to their
authorized representative, the person must specifically authorize that release. In this example, Jane has agreed to
let her daughter Suzy Smith receive her SPHI.
Section III-B is where the person specifies what PHI they are authorizing BCBSNM to release. In this example, Jane
is authorizing BCBSNM to release claims information from 6-12-15 to 4-30-18 to her daughter Suzy Smith.
B. Description of PHI to be released. You may select one or more
Dates of Services
From: To:
Health Plan
Benefit
Information:
Includes information contained in your benefit
booklet (i.e., copayments, coinsurance, eligibility
and other benefit information).
Claims
Information:
Includes information related to payment of your
claims for service you received, including pertinent
information located on a claim form (i.e., billed
amount, general procedure descriptions claim
payment or denial reasons, etc.).
06-12-15
04-30-18
Service
Determination
Information:
Includes any information related to pre-service,
concurrent and post-service decisions.
Premium
Information:
Includes information related to billing cycles, bank
draft changes, etc.
Services
from Provider
or Supplier:
Provider/Supplier Name:
________________________________________________
Describe the exact information you want released:
Other:
Add other information that is not listed above.
X
Yes
No
X
Rev 04/01/18 – HCSC Privacy Office (04/23/19 – BORC) Page 3 of 6 SAF-NM
Section IV. Expiration & Right to Revoke or Terminate the Authorization
Expiration: Select a date/event when authorization will expire. The authorization cannot be processed if this is left blank.
One year from the date it is signed Other (insert date or event):
Right to Revoke/Terminate: You may end this authorization at any time by giving written notice to BCBSNM at the
address listed below; however, BCBSNM is not responsible for the PHI released before the authorization was
terminated.
In Section IV, the person must select a date when this authorization will end. All valid authorizations must contain a
specific expiration date or event; for example: “hospitalization end date”, “rehabilitation end date”, etc. In addition,
BCBSNM is providing information about the right to terminate an authorization at any time. In this example, the
authorization remains valid for one year from the date it was signed unless Jane revokes it.
_______________________________________________________________________________________________
Section V. Signature & Acceptance of Terms.
I understand that this authorization is voluntary and that the health plan cannot condition my eligibility for benefits,
treatment, enrollment or payment of claims on the signing of this authorization.
Self
4-30-18
Signature
Relationship
Date (MM-DD-YY)
Document must be signed by the person, the parent of a minor child or the person’s authorized representative. If you
are a parent signing on behalf of a minor child, please sign your name – not the child’s name. This authorization will
expire when the minor child turns 18 years of age, unless proof of legal guardianship is produced. If you are signing
Sas a Power of Attorney, Legal Guardian, Executor or Administrator complete the following and provide copies of the
appropriate Legal documents. If these documents are already on file with BCBSNM, you do not need to provide.
Authorized Representative’s Name
Relationship to Person
Authorized Representative’s Address
City
State
Zip Code
Authorized Representative’s Area Code & Phone Number
In Section V, the person identified in Section I signs the form unless the person identified in Section I is a minor
under the age of 18 – then the parent or guardian signs the form. In this example, Jane is signing on her own behalf.
However, if Jane was a minor, her parent or guardian would sign their name on the form.
Before sending this form, make a copy for your records:
•
Photocopy this signed authorization, or
•
Complete and sign the duplicate form you received
or printed
The rest of the form contains instructions for submitting the form to BCBSNM.
Please keep a signed copy for your records.
X
Jane Doe
Rev 04/01/18 – HCSC Privacy Office (04/23/19 – BORC) Page 4 of 6 SAF-NM
Standard Authorization Form to Release
Protected Health Information (PHI)
Use this form to authorize Blue Cross and Blue Shield of New Mexico (BCBSNM) to disclose your protected health
information (PHI) to a specific person or entity. You may follow the instructions below or call the number listed on your
Member ID card if you need help completing the form. You must complete the entire form.
Please note:
• One authorization form can be used for multiple services or providers or you can complete the form claim by
claim, procedure by procedure, or for services provided during certain time periods.
• The use of the authorization form is voluntary.
_______________________________________________________________________________________________
Section I. Name and information of person whose PHI is being disclosed
Name Date of Birth
Group Number Identification/Subscriber Number Social Security Number
Address City
State Zip Code Area Code & Phone Number
The information in Section I applies to the person whose PHI is being disclosed. The person could be the policy holder,
his or her spouse, a dependent or any other person covered under the policy or a person who has their own coverage.
_______________________________________________________________________________________________
Section II. Authorization and Purpose
I authorize BCBSNM to release my PHI to the person or organization listed below. I understand if the person or
organization listed below is not a health plan or health care provider, the PHI may not be protected by federal privacy laws.
Persons/Organizations authorized to receive your information Relationship
Purpose
Address City State Zip Code
The information in Section II identifies the person or organization that will be receiving the PHI about the person named
in Section I. A person that needs access to the PHI could be a family member, a close friend, a broker, or an attorney.
If the person wants PHI to go to an organization, please include the area and/or job title of the person at the organization,
for example, Benefits Representatives, Human Resources Department, Associate XYZ Insurance Agency, etc.
Rev 04/01/18 – HCSC Privacy Office (04/23/19 – BORC) Page 5 of 6 SAF-NM
Section III. Description of Sensitive Protected Health Information (SPHI) and PHI to be Released
Complete Parts A and B of this section
A. Release of SPHI that may be protected under State Law. If you check “yes,” you are authorizing BCBSNM to
release the SPHI listed below and if applicable to your data release request, it will be included in the information you
select in III.B. If you check “no” or make no selection at all, SPHI will not be released. This authorization may not be used
for the release of Psychotherapy Notes.
• Human Immunodeficiency Virus (HIV) or HIV/Acquired Immune Deficiency Syndrome,
•
Sexually transmitted or “communicable” diseases (includes hepatitis, as well as venereal
diseases),
• Drug, alcohol or substance abuse,
•
Mental health or developmental disabilities (including mental retardation or similar disabilities,
for example, those attributable to cerebral palsy, autism or neurological dysfunctions), and
• Genetic testing.
The information in Section III-A applies when a person wants specific SPHI as listed above to be released to their
authorized representative, the person must specifically authorize that release.
Section III-B is where the person specifies what PHI they are authorizing BCBSNM to release.
B. Description of PHI to be released. You may select one or more. Dates of Services
From: To:
Health Plan
Benefit
Information:
Includes information contained in your benefit
booklet (i.e., copayments, coinsurance, eligibility
and other benefit information).
Claims
Information:
Includes information related to payment of your
claims for service you received, including pertinent
information located on a claim form (i.e., billed
amount, general procedure descriptions claim
payment or denial reasons, etc.).
Service
Determination
Information:
Includes any information related to pre-service,
concurrent and post-service decisions.
Premium
Information:
Includes information related to billing cycles, bank
draft changes, etc.
Services
from Provider
or Supplier:
Provider/Supplier Name:
________________________________________________
Describe the exact information you want released:
Other:
Add other information that is not listed above.
Yes
No
Rev 04/01/18 – HCSC Privacy Office (04/23/19 – BORC) Page 6 of 6 SAF-NM
Section IV. Expiration & Right to Revoke or Terminate the Authorization
Expiration: Select a date/event when authorization will expire. The authorization cannot be processed if this is left blank.
One year from the date it is signed Other (insert date or event):
Right to Revoke/Terminate: You may end this authorization at any time by giving written notice to BCBSNM at the
address listed below; however, BCBSNM is not responsible for the PHI released before the authorization was
terminated.
In Section IV, the person must select a date when this authorization will end. All valid authorizations must contain a
specific expiration date or event; for example: “hospitalization end date”, “rehabilitation end date”, etc. In addition,
BCBSNM is providing information about the right to terminate an authorization at any time.
_______________________________________________________________________________________________
Section V. Signature & Acceptance of Terms.
I understand that this authorization is voluntary and that the health plan cannot condition my eligibility for benefits,
treatment, enrollment or payment of claims on the signing of this authorization.
Signature Relationship Date (MM-DD-YY)
Document must be signed by the person, the parent of a minor child or the person’s authorized representative. If you
are a parent signing on behalf of a minor child, please sign your name – not the child’s name. This authorization will
expire when the minor child turns 18 years of age, unless proof of legal guardianship is produced. If you are signing
as a Power of Attorney, Legal Guardian, Executor or Administrator complete the following and provide copies of the
appropriate Legal documents. If these documents are already on file with BCBSNM, you do not need to provide.
Authorized Representative’s Name Relationship to Person
Authorized Representative’s Address City
State Zip Code Authorized Representative’s Area Code & Phone Number
Before sending this form, make a copy for your records:
•
Photocopy this signed authorization, or
•
Complete and sign the duplicate authorization form
If you need assistance completing the form, refer to the instructions above
or call the number listed on your Member ID Card.
Mail the signed authorization to:
Blue Cross and Blue Shield of New Mexico
PO Box 805107
Chicago, IL 60680-4112
click to sign
signature
click to edit
bcbsnm.com
Health care coverage is important for everyone.
We provide free communication aids and services for anyone with a disability or who needs language
assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age,
sexual orientation, health status or disability.
To receive language or communication assistance free of charge, please call us at 855-710-6984.
If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.
Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail)
300 E. Randolph St. TTY/TDD: 855-661-6965
35th Floor Fax: 855-661-6960
Chicago, Illinois 60601 Email: CivilRightsCoordinator@hcsc.net
You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:
U.S. Dept. of Health & Human Services Phone: 800-368-1019
200 Independence Avenue SW TTY/TDD: 800-537-7697
Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html
Rev 04/23/19
If you, or someone you are helping, have questions, you have the right to get help and information
in your language at no cost. To talk to an interpreter, call 855-710-6984.
Español
Spanish
Si usted o al
g
uien a quien usted está a
y
udando tiene pre
g
untas, tiene derecho a obtener a
y
uda e
información en su idioma sin costo al
g
uno. Para hablar con un intérprete, llame al 855-710-6984.

A
rabic

  
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 .


  
6984-710-855.
繁
體
中文
Chinese
如
果
您
,
或您
正
在協助的對象
,
對
此
有
疑問,
您有權利免費
以
您的
母
語獲得幫助
和
訊息
。
洽詢一位翻譯員, 請撥電話 號碼
855-710-6984。
Français
French
Si vous, ou quelqu'un que vous êtes en train d’aider, avez des questions, vous avez le droit d'obtenir de
l'aide et l'information dans votre lan
g
ue à aucun coût. Pour parler à un interprète, appelez 855-710-6984.
Deutsch
German
Falls Sie oder
j
emand, dem Sie helfen, Fra
g
en haben, haben Sie das Recht, kostenlose Hilfe und
Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die
Nummer 855-710-6984 an.

Gujarati

 
 




.
.
. 

  ,    ,        .
    
 855-710-6984
  .

Hindi


,



,

,






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
.
Italiano
Italian
Se tu o qualcuno che stai aiutando avete domande, hai il diritto di ottenere aiuto e informazioni nella tua
lin
g
ua
g
ratuitamente. Per parlare con un interprete, puoi chiamare il numero 855-710-6984.
한국어
Korean
만약 귀하 또는 귀하가 돕는
사람이
질문이
있다면
귀하는
무료로 그러한 도움과
정보를
귀하의 언어로 받을 수 있는 권리가 있습니다. 통역사가 필요하시면 855-710-6984 로
전화하십시오.
Diné
Navajo
T’11 ni, 47 dooda
g
o [a’da b7k1 an1n7lwo’7
g
77, na’7d7[kid
g
o, ts’7d1 bee n1 ah00ti’i’ t’11 n77k’e
n7k1 a’doolwo[ d00 b7na’7d7[kid7g77 bee ni[ h odoonih. Ata’dahalne’7g77 bich’8’ hod77lnih kwe’4
855-710-6984.
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


 .  
    855-710-6984   .
Polski
Polish
Jeśli T
y
lub osoba, które
j
poma
g
asz, macie
j
akiekolwiek p
y
tania, macie prawo do uz
y
skania
bezpłatnej informacji i pomocy we własnym języku. Aby porozmawiać z tłumaczem, zadzwoń pod
numer 855-710-6984.
Русский
Russian
Если
у
вас или человека, котором
у
вы помогаете, возникли вопросы,
у
вас есть право на бесплатн
у
ю
помощь и информацию, предоставленную на вашем языке. Чтобы связаться с переводчиком,
позвоните по телефон
у
855-710-6984.
Tagalog
Tagalog
Kun
g
ikaw, o an
g
isan
g
taon
g
i
y
on
g
tinutulun
g
an a
y
ma
y
m
g
a tanon
g
, ma
y
karapatan kan
g
makakuha n
g
tulong at impormasyon sa iyong wika nang walang bayad. Upang makipag-usap sa isang tagasalin-wika,
tumawa
g
sa 855-710-6984.

Urdu
    
       
       

 

 
    855-710-6984   
Ti
ng Vit
Vietnamese
N
u quý v, hoc ngi mà quý v giúp , có câu hi, thì quý v có quy
n c giúp  và nhn thông tin
bn
g
n
g
ôn n
g
ca mình min phí.
nói chu
y
n vi mt thôn
g
dch viên,
g
i
855-710-6984.
bcbsnm.com
Rev 04/23/19
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